Basic Information
| Provider Information | |||||||||
| NPI: | 1003150384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAGATAC | ||||||||
| FirstName: | MARELLA | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8333 BRAESMAIN DR | ||||||||
| Address2: | # 1404 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770252940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583546854 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8333 BRAESMAIN DR | ||||||||
| Address2: | # 1404 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770252940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583546854 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2012 | ||||||||
| LastUpdateDate: | 11/26/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 28449 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.